Part two - anatomy

Question 1

What are the boundaries of the cubital fossa?

Answer 1

Superior - line joining humeral condyles
Medial - radial border pronator teres
Lateral - ulnar border brachioradialis

Floor - brachialis and supinator

Roof - deep fascia of forearm reinforced medially by bicipital aponeurosis over which lies median cubital vein and medial cutaneous nerve of the forearm

Question 2

What are the contents of the cubital fossa?

Answer 2

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• Biceps tendon
• Brachial artery
• Median nerve

If brachioradialis retracted and see radial nerve and its posterior interosseous branch which gives branches to ECRB and supinator.

Question 3

Contents of anterior compartment of leg

Answer 3

Muscles
      * Tibialis anterior
      * Extensor hallucis longus
      * Extensor digitorium longus
      * Peroneus tertius
Nerve
      * Deep perineal nerve
Artery 
      * Anterior tibial artery

Question 4

Order of anterior structures at the ankle

Answer 4

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From the Medial Malleolus going laterally

  * Tibialis anterior
  * Extensor Hallucis longus
  * Anterior tibial Artery
  * Deep perineal Nerve
  * Extensor Digitorium longus
  * Peroneus Tertius

Question 5

Contents of the lateral compartment of the leg

Answer 5

Muscles
      * Peroneus longus
      * Peroneus brevis
Nerve
      * Superficial peroneal nerve

Question 6

What are the layers of the chest wall you go through to place a chest drain?

Answer 6

Skin
Subcutis
External intercostal muscle
Internal intercostal muscle
Innermost intercostal muscle
Endothoracic fascia
Parietal pleura
Pleural cavity

Question 7

Blood supply to diaphragm

Answer 7

Superior phrenic a - thoracic aorta
Inferior phrenic a - abdominal aorta
Musculophrenic a - internal thoracic artery

Question 8

What is the Cernea Classification?

Answer 8

Classification for the relationship between the ESLN and the superior thyroid vessels:

• Type I = nerve crosses ST vessels >1cm above upper pole
• Type IIa = nerve crosses STV < 1cm above upper pole
• Type IIb = nerve crosses at or below level of upper pole

Question 9

Constrictions of the oesophagus

Answer 9

15cm - cricopharyngeus at C6
22cm - aortic arch
27cm - left main bronchus
38cm - hiatus at T10

Question 10

Embryology of oesophagus

Answer 10

Shares common embryologic origin with the trachea which it separates from at 6 weeks

Question 11

Structure of the oesophagus

Answer 11

Stratified squamous epithelium
Muscular layers - inner circular, outer longitundinal
* Upper 1/3 striated
* Middle 1/3 mixed
* Lower 1/3 smooth

Question 12

What is the phrenoeophageal ligament?

Answer 12

Fascial cone of transversalis fascia on the undersurface of the diaphragm which extends through the oesophageal opening and blends with the endothoracic fascia above the diaphragm.
It is attached to the oesophagus 2-3cm above GOJ.

Question 13

Pectoralis minor

Answer 13

3rd-5th ribs -> coracoid process
Divides axillary artery into three parts
Lateral and medial pectoral nerves

Question 14

Serratus anterior

Answer 14

Digitations first 8 ribs near costal cartilages
Medial scapular border
Long thoracic nerve = C5-7

Question 15

Subscapularis

Answer 15

Costal scapular surface
Lesser tuberosity of humerus
Subscapular nerves

Question 16

Teres major

Answer 16

Scapular inferior angle -> bicipital groove

Lower sub scapular nerves

Question 17

Actions of latissimus dorsi

Answer 17

Extends, adducts and medially rotates arm

Question 18

Iliopectineal arch

Answer 18

• strong fascia overlying iliopsoas muscle
  
  • divides space deep to inguinal ligament into two
  • blends with inguinal ligament in front
  • blends with pectineal ligament behind

Question 19

Ilipoubic tract

Answer 19

The inguinal ligament of the transversalis fasci

  * arises from iliopetineal arch
  * runs parallel with but deeper than inguinal ligament
  * curves around femoral vessels and canal
  * blends with pectineal ligament
  * forms anterior and medial walls of femoral sheath

Question 20

Why are patients at risk of a direct inguinal hernia after open appendicectomy

Answer 20

Lowermost fibres of IOM and transversus supplied by L1 nerves which if divided can lead to a direct hernia due to bulging of the conjoint tendon with increased intra-abdominal pressure. At the level of the inguinal canal, however, the ilioinguinal is purely a sensory nerve (anterior scrotum/labia and adjacent thigh).

Ilioinguinal - 2cm superomedial to ASIS
Iliohypogastric - 3cm superomedial to ASIS

Question 21

External oblique muscle

Answer 21

Lower 8 ribs anterior angles (5-12)
Anterior half iliac crest, xiphisternum, PS & crest, linea alba
3 free edges
- posteriorly
- inguinal ligament
- between 5th rib and xiphi superiorly
T7-12 intecostal nerves

Question 22

Internal oblique

Answer 22

Costal margin, rectus sheath , linea alba
Anterior 2/3 iliac crest, lateral 2/3 inguinal ligament, lumbar fascia
Conjoint tendon to pubic crest and pectineal line
T7-T12 & ilioinguinal nerve (L1) to conjoint tendon
Fibres at right angles to EOM - up and medial

Question 23

Transversus abdominis

Answer 23

Costal margin, rectus sheath, linea alba
Anterior 2/3 iliac crest, lateral 1/2 inguinal ligament, lumbar fascia
Conjoint tendon to pubic crest and pectineal line
Transverse fibres
T7-T12 & ilioinginal nerve to conjoint tendon

Question 24

Rectus abdominis

Answer 24

Costal cartilages 5-7, costal margin, sternum, diaphragm
Pubic crest, tubercle and symphysis
T7-12
3 tendinous intersections fused to anterior rectal sheath
- xiphi
- umbo
- halfway

Question 25

Pyramidalis

Answer 25

Front of pubis body to line alba

T12 (subcostal)

Question 26

Blood supply to the nipple

Answer 26

Periareolar subcutaneous plexus supplied by:
Superficial branches of internal and lateral thoracic arteries from above
Branches of the lower intercostal vessels from below

Question 27

Pectoralis major

Answer 27

Three origins
- Medial half of clavicle, deltopectoral groove
- Lateral half of sternum
- 2nd-6th costal cartilages
Inserts into bicipital groove
Medial (C8) and lateral pectoral nerves (C6-7) which paradoxically innervate the lateral and medial fibres respectively

Question 28

Lumbar plexus

Answer 28

T12 - subcostal
L1 - iliohypogastric & ilioinguinal
L1,L2 - genitofemoral
L2,L3 - lateral femoral cutaneous
L2-4 posterior divisions - femoral nerve
L2-4 anterior divisions - obturator nerve
L4,L5 - lumbosacral trunk

Question 29

Genitofemoral nerve

Answer 29

L1,L2
Pierces psoas and runs on it
Genital branch enters cord with cremasteric vessels
Lies posterior to cord
Supplies cremaster muscle and skin of scrotum/labia and medial thigh

Question 30

Branches of the external iliac artery

Answer 30

Deep circumflex artery
Inferior epigastric artery
–> cremaster artery
–> superior pubic branch

Question 31

Femoral sheath

Answer 31

Pectineal ligament and pectineus fascia posterolaterally
Transversalis fascia anteromedially
Divided into three compartments:
- Lateral --> artery
- Middle --> vein
- Medial --> femoral canal

Ends 4cm below inguinal ligament by fusing with the adventitia of the vessels

Question 32

Pancreatic divisim

Answer 32

Most common congenital pancreatic anomaly
7% in autopsies
Failure of fusion of the ventral and dorsal ductal systems

Question 33

Annular pancreas

Answer 33

Uncommon
Complete ring of pancreatic tissue around D2 resulting from failure of ventral bud to rotate with duodenum
Children present with duodenal obstruction
Adults - peptic ulcers, duodenal obstruction, acute or chronic pancreatitis, obstructive jaundice